Low Child Survival Index in a Multi-Dimensionally Poor Amerindian Population in Venezuela Julian A. Villalba1,2,3*, Yushi Liu3, Mauyuri K. Alvarez4, Luisana Calderon4, Merari Canache4, Gaudymar Cardenas4, Berenice Del Nogal4,5, Howard E. Takiff6, Jacobus H. De Waard2 1 Dirección Regional de Salud Estado Delta Amacuro, Tucupita, Venezuela, 2 Laboratorio de Tuberculosis, Instituto de Biomedicina, Caracas, Venezuela, 3 Lovelace Respiratory Research Institute, Albuquerque, New Mexico, United States of America, 4 Escuela de Medicina José María Vargas, Universidad Central de Venezuela, Caracas, Venezuela, 5 Departamento de Pediatría, Hospital de Niños “J.M. de los Ríos”, Caracas, Venezuela, 6 Laboratorio de Genética Molecular, Instituto Venezolano de Investigaciones Científicas, Caracas, Venezuela
Abstract Background: Warao Amerindians, who inhabit the Orinoco Delta, are the second largest indigenous group in Venezuela. High Warao general mortality rates were mentioned in a limited study 21 years ago. However, there have been no comprehensive studies addressing child survival across the entire population. Objectives: To determine the Child Survival-Index (CSI) (ratio: still-living children/total-live births) in the Warao population, the principal causes of childhood death and the socio-demographic factors associated with childhood deaths. Methods: We conducted a cross-sectional epidemiological survey of 688 women from 97 communities in 7 different subregions of the Orinoco Delta. Data collected included socio-demographic characteristics and the reproductive history of each woman surveyed. The multidimensional poverty index (MPI) was used to classify the households as deprived across the three dimensions of the Human Development Index. Multivariable linear regression and Generalized Linear Model Procedures were used to identify socioeconomic and environmental characteristics statistically associated with the CSI. Findings: The average CSI was 73.8% ±26. The two most common causes of death were gastroenteritis/diarrhea (63%) and acute respiratory tract Infection/pneumonia (18%). Deaths in children under five years accounted for 97.3% of childhood deaths, with 54% occurring in the neonatal period or first year of life. Most of the women (95.5%) were classified as multidimensionally poor. The general MPI in the sample was 0.56. CSI was negatively correlated with MPI, maternal age, residence in a traditional dwelling and profession of the head of household other than nurse or teacher. Conclusions: The Warao have a low CSI which is correlated with MPI and maternal age. Infectious diseases are responsible for 85% of childhood deaths. The low socioeconomic development, lack of infrastructure and geographic and cultural isolation suggest that an integrated approach is urgently needed to improve the child survival and overall health of the Warao Amerindians. Citation: Villalba JA, Liu Y, Alvarez MK, Calderon L, Canache M, et al. (2013) Low Child Survival Index in a Multi-Dimensionally Poor Amerindian Population in Venezuela. PLoS ONE 8(12): e85638. doi:10.1371/journal.pone.0085638 Editor: Thomas Eisele, Tulane University School of Public Health and Tropical Medicine, United States of America Received January 20, 2013; Accepted December 5, 2013; Published December 31, 2013 Copyright: © 2013 Villalba et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The authors have no support or funding to report. Competing interests: The authors have declared that no competing interests exist. * E-mail: [email protected]
The latest census showed that 81.4% of the Warao lived in the LOD, 15.2% in the IOD and 3.4% in the UOD . The Warao live under precarious sanitary conditions [5-7] in approximately 364 villages  along the banks and on the islands of the Orinoco distributaries , generally with minimal infrastructure and very limited access to medical attention [5,7,8]. There are no roads or ground transportation in the Delta [5,7]. Recent studies have documented many of the severe health problems afflicting the Warao communities:
According to last official Venezuelan Census (2001), the Warao people are the second largest Amerindian group in Venezuela . They live mainly in the Orinoco River Delta; a fan of alluvial deposits within the coastal plain of eastern Venezuela subdivided by networks of fluvial and tidal channels , which is divided into three major geographical regions: upper (UOD), intermediate (IOD) and lower delta (LOD) .
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respiratory tract infections(RTI) , tuberculosis [10,11], viral hepatitis [12,13] and HIV [14,15]. A critical problem is the lack of clean drinking water [6,7,16,17]. The Orinoco river, which Warao people have been drinking since ancestral times [8,18], has both organic  and inorganic pollution . In addition, although most Warao still live in their original habitat [5,7], a sizable minority have recently experienced an accelerated process of acculturation , moving from their traditional villages within the Orinoco Delta to settle in “new” communities surrounding nearby urban centers such Puerto Ordaz and Tucupita, where they live in marginal communities that generally lack basic services [5,7,20]. Since most Warao people have no access to birth and death registration centers, there are very few statistics on mortality rates and causes of death in infants, children, adults and elderly. An investigation carried out from 1990-1993  in a small geographical area estimated the total mortality rate per year in the Warao population as 12/1000 individuals, which was much higher than the mortality rate of 5/1000 for the general Venezuelan population during the same period . That survey found that infectious diseases, principally gastroenteritis and tuberculosis, were the most common cause of death (46.5%). Other respiratory diseases, accounted for 8.2% of deaths, and 2.8% of deaths were associated with childbirth. The report also noted that in 60% of deaths, the individuals did not receive medical attention for the cause of death during the preceding six months . As the mortality data from the prior study is now 21 years old, and there is no available data on infant mortality, we believed that another study was urgently needed. The objectives of the present study were to: 1) measure the child survival-index (CSI); 2) determine causes of child deaths; and 3) evaluate the socio-demographic factors associated with childhood deaths.
Warao have recently migrated [7,20,23] (Figure 1). Due to logistical problems, Amacuro was the only subregion of the LOD excluded in our study. Inclusion of IOD was not within our objectives. The seven subregions that we studied contained an estimated 9305 women, 74% of the total female Warao population.
Epidemiologic Data Collection The survey was conducted between October and November 2011, using a cluster sampling approach (Figure 2). The sampling was based on the three municipalities that have Warao population in the DA, using the list of communities appearing in the 2001 Venezuelan census  as the sampleframe. The proportion of communities selected from each municipality corresponded to the percentage of Warao communities that were located within the municipality (Table S1). The method for random selection of the communities to be sampled, and the geographic location and the size of the studied communities are given in the Methods S1 and Tables S2 and S3, respectively. To reach all the communities included in the study we traveled in small outboard boats along the Orinoco distributaries and streams for a total of 4825 Kilometers (2998 miles). Within each community a systematic sampling technique was used to select houses to be interviewed (Methods S1), and within each selected house, all women who reported at least one lifetime pregnancy were invited to participate. The only exclusion criterion was refusal to sign an informed consent. All of the women in our study responded to a questionnaire with simultaneous translation to and from the Warao language by Spanish-Warao bilingual native interpreters. The questionnaire inquired about: 1) indicators of socioeconomic status, 2) level of literacy/education of the interviewed women and their husbands, 3) parity, and 4) the total number of children per woman according to the following categories: stillbirths, live-births, live-births who died and living children. Stillbirths were defined as any fetal death in which mothers could perceive human characteristics and shape in the fetus. In addition, we asked about any children who died in 2011, the year in which the study was carried out. The women were also questioned as to the causes of child deaths, which were classified according to the International Classification of Diseases (ICD-10) . Maternal and paternal ages were determined from the national identity cards. The child survivalindex (CSI) was defined as the ratio of still-living children to total-live births per Warao woman. The Multidimensional Poverty Index (MPI) was used to classify the households as deprived across the three dimensions of the Human Development Index (Health, Education and Living Standards). The original MPI [25,26] was modified slightly such that all the indicators were included except “nutritional status”, which was not assessed in the study. A detailed description of the dimensions and indicators used is further described in the Methods S2.
Methods Ethics Approval This study was conducted in compliance with the Venezuelan Law on Indigenous People and Communities. Verbal and written permission to carry out the study was obtained from community leaders as well as the Office of Health Programs of Delta Amacuro State (DA) and SAOI -- the Office responsible for Indigenous Health in DA. Both offices approved the project and granted the authors permission to publish the results. Women participating in the study signed a written informed consent. Illiterate women signed by means of a thumbprint. The Venezuelan Ministry of Health and the Pan American Health Organization received written reports of the results of the study prior to submission for publication.
Population In the 2001 Venezuelan National Census there were 26.080 Warao residing in DA, of which 48% were women[1,4]. The current epidemiological cross-sectional study was carried out in 97 communities (27% of the total Warao communities)  in seven different subregions of the LOD -- the original habitat of Warao tribe, -- and the UOD -- the principal area to which the
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Statistical Evaluation The data was analyzed using Microsoft Excel, and the results reported as mean ±SD. The entire data collected in the
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Figure 1. Map of the Orinoco Delta. Studied subregions are shown inside the black rectangles: Upper Orinoco Delta (A), Manamo Distributary (B), Capure distributary-Waranoko Surroundings (C), Mariusa Atlantic Coastline-Makareo Distributary (D), Nabasanuka surroundings (E), Guayo surroundings (F) and Curiapo surroundings (G). The red rectangle corresponds to Amacuro subregion which was not included in our survey. Triangles inside boxes correspond to the 97 studied communities. doi: 10.1371/journal.pone.0085638.g001
study is provided as Datasets S1 and S2. Sexspecific differences between parents were analyzed using Pearson's chi-squared test. An error probability (P value) of